Page 39 - USUI Benefit Book
P. 39
$200 $25 $125 0% $1,900 $200 $200 $0 $0 $400 7 of 8
copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different
amounts (deductibles, (in-network emergency room visit and follow up care) overall deductible Specialist copayment Hospital (facility) copayment This EXAMPLE event includes services like: Emergency room care (including medical Cost Sharing
might cover medical care. Your actual costs will be different
charge, and many other factors. Focus on the cost sharing
The Other coinsurance supplies) Diagnostic tests (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost In this example, Mia would pay: Deductibles Copayments Coinsurance Limits or exclusions The total Mia would pay is
$200 $25 0% $7,400 $200 $800 $0 $60 $1,060
$
health plans. Please note these coverage examples are based on self-only coverage.
(a year of routine in-network care of a well-controlled condition) overall deductible Specialist copayment Hospital (facility) copayment 125 This EXAMPLE event includes services like: Primary care physician office visits (including Durable medical equipment (glucose meter) In this example, Joe would pay: Cost Sharing
This is not a cost estimator. Treatments shown are just examples of how this plan
depending on the actual care you receive, the prices your providers
The Other coinsurance disease education) Diagnostic tests (blood work) Prescription drugs Total Example Cost Deductibles Copayments Coinsurance Limits or exclusions The total Joe would pay is The plan would be responsible for the other costs of these EXAMPLE covered services.
$200 $25 $125 0% $12,700 $200 $200 $0 $60 $460
About these Coverage Examples: Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) overall deductible The Specialist copayment Hospital (facility) copayment Other coinsurance This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Special
